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Provider Network Audit Quality Specialist



Quality Assurance
North Aurora, IL, USA
Posted on Monday, June 10, 2024

Bring your heart to CVS Health. Every one of us at CVS Health shares a single, clear purpose: Bringing our heart to every moment of your health. This purpose guides our commitment to deliver enhanced human-centric health care for a rapidly changing world. Anchored in our brand — with heart at its center — our purpose sends a personal message that how we deliver our services is just as important as what we deliver.

Our Heart At Work Behaviors™ support this purpose. We want everyone who works at CVS Health to feel empowered by the role they play in transforming our culture and accelerating our ability to innovate and deliver solutions to make health care more personal, convenient and affordable.

Family Summary/Mission Acts as an Advocate for, and support, the business by serving as a quality champion through measuring and monitoring the quality and effectiveness of work processes in claim processing and/or customer service that impact customer satisfaction, medical cost management, and operational efficiency. Consult and/or work cross functionally to influence and promote change in order to continually deliver quality service to our internal and external customers.

Position Summary/Mission Performs routine quality audits for network operations, and claim testing for PPO Network creation.

Fundamental Components & Physical Requirements include but are not limited to
(* denotes essential functions)

• Conduct standard quality reviews /audits to measure compliance with published policies, procedures, customer and regulatory guidelines (*)

• Identify and distribute errors to business partners (*)

• Assist with the day-to-day maintenance and operations of assigned functional unit (*)

• Perform analysis of data to identify and communicate trends during day to day work (*)

• May perform or assist with special projects/reviews

• May provide technical or subject matter expertise concerning policies, procedures, and function-related applications/systems tools

• Subject matter expert on workflows, policies, components of systems and on daily operations and programs

• Responsible to support targeted quality audit projects. Report results and make recommendations e.g., training needs, quality controls and procedures)

• In partnership with business owners, support the design and development of new processes

• Develop and implement quality programs and initiatives. Participate in the development and validation of master or detail test plans and strategies

• Analyze and resolve complex claims scenarios within established time frames

• Resolves problems in a timely and effective manner.

• Uses designated systems to obtain information. Understands the impact of actions on system primarily used/maintained. Understands relationships of designated systems.

• Analyzes and verifies system results to ensure accuracy, accountability and financial data integrity.

• Possesses working knowledge of functions of other units in department Responds to and resolves customer inquiries and complaints (internal as well as external) both verbal and written correspondence within established unit objectives.

• Analyzes and resolves system error conditions within established unit time frames.

• Analyzes and recommends solutions to non-standard requests and requirements from plan sponsors and areas within and outside the area.

• Monitors, reviews, researches, reconciles and balances designated Aetna system activity.

Background/Experience Desired 1 – 3+ years work experience in the audit environment that reflects a proven track record or proficiency in the competencies noted. Experience with claims testing, and a working knowledge of PPO’s.

Education and Certification Requirements High school diploma or equivalent.

Pay Range

The typical pay range for this role is:

$18.50 – $37.02

This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors. This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above.

In addition to your compensation, enjoy the rewards of an organization that puts our heart into caring for our colleagues and our communities. The Company offers a full range of medical, dental, and vision benefits. Eligible employees may enroll in the Company’s 401(k) retirement savings plan, and an Employee Stock Purchase Plan is also available for eligible employees. The Company provides a fully-paid term life insurance plan to eligible employees, and short-term and long term disability benefits. CVS Health also offers numerous well-being programs, education assistance, free development courses, a CVS store discount, and discount programs with participating partners. As for time off, Company employees enjoy Paid Time Off (“PTO”) or vacation pay, as well as paid holidays throughout the calendar year. Number of paid holidays, sick time and other time off are provided consistent with relevant state law and Company policies.

For more detailed information on available benefits, please visit jobs.CVSHealth.com/benefits

We anticipate the application window for this opening will close on: 06/28/2024